Member Forms

Use our forms to help manage your health plan and flexible spending account (FSA). If you have any questions, contact Customer Service using the number on your ID card.

Over-the-counter (OTC) COVID-19 Tests

Please do NOT use the claim forms posted here to submit a claim for over-the-counter (OTC) COVID-19 tests. Please see the section below that outlines the process for those claims.

Claim Forms

Medical
Mail this form to the address listed on the back of your member identification (ID) card.

Dental
Mail this form to: Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018

Vision
Mail this form to: Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018

Prescription Drug Claim form for Major Medical Benefits
For members with one deductible for both covered medical and prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.

Prescription Drug Claim form for Drug Card Benefits
For members with separate deductibles for covered medical claims and covered prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.

Prescription Drug Claim form for Drug Card Benefits (on exchange)
For members who bought a plan on the federal exchange and have separate deductibles for covered medical claims and covered prescription drug claims. Please Note: Use this form only if you forgot your ID card at time of purchase. You will maximize your benefits and be guaranteed the lowest price when you use your ID card at time of purchase.

Over the Counter (OTC) COVID-19 Test Reimbursement Claim Form (log in to My Health Plan)
The public health emergency which was declared in response to COVID-19 ended May 11, 2023. As a result, OTC COVID-19 test kits are no longer required to be covered. Office, emergency room, urgent care, and telehealth visits for testing, as well as the COVID-19 test performed during that visit, continue to be covered but are subject to member cost sharing.

Miscellaneous Forms

Adult Dependent Form
Mail this form to: Medical Mutual, P.O. Box 943, Toledo, OH 43656-0001

Disability Verification
Mail this form to: Medical Mutual,100 American Road, Cleveland, OH 44144

Prescription Drug Home Delivery Form
This form is for members with prescription drug benefits through Express Scripts.

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